Solid cyst. Cystic-solid brain tumor: causes, consequences, treatment

Many renal masses are not palpable on examination until the very late stage of the disease. As a rule, kidney cancer is a solid mass of the kidney, which in half of the cases of renal cell carcinoma is diagnosed quite by accident during various tests for another disease. Today, the classic triad of symptoms (macrohematuria, flank pain, and palpable abdominal mass) that accompany various types of malignant renal neoplasms is very rare. That is why it is very important to identify the disease in a timely manner. For this, modern diagnostic methods and equipment are used.

Clinical picture

What is a solid kidney formation, we figured out - it's kidney cancer. Only a third of patients with this disease have the following symptoms, indicating the likelihood of a malignant kidney tumor:

• cachexia;
• high blood pressure;
• fever;
• weight loss;
• amyloidosis;
• neuromyopathy;
• anemia;
• increase in ESR;
• disorders in the liver;
• polycythemia;
• hypercalcemia.

Worth knowing: in addition to the listed symptoms, some patients may have signs of a metastatic process, namely a persistent cough and bone pain.

Diagnostics

Any kidney formations must be differentiated from other kidney diseases. That is why a whole range of procedures is carried out in the diagnostic process:

1. Physical examination is not very important in terms of diagnosis. However, if the following symptoms are found during it, this is an occasion for a more detailed examination of the patient:

• enlarged cervical lymph nodes;
• a tumor is palpated in the abdominal cavity;
• permanent varicocele;
• involvement in the process of the venous system may be indicated by bilateral edema of the legs.

1. Laboratory diagnostic methods. The most commonly used parameter is serum creatinine, GFR, hemoglobin level, ESR, serum calcium concentration, alkaline phosphatase and LDH - lactodehydrogeniasis. Separately, the functions of both kidneys are evaluated in such cases:

• if, according to the high content of creatinine in the blood, a decrease in the activity of the organ can be assumed;
• if there is a risk of a significant decrease in kidney function during treatment;
• in patients with concomitant diseases that can provoke a decrease in renal function (pyelonephritis, diabetes, renovascular disease, ICD, polycystic kidney disease).

1. Radiation diagnostics. Many renal masses are well visualized on CT or during ultrasound for another disease. At the same time, according to visualization, renal neoplasms can be divided into cystic and solid.
2. The presence of contrast. The main distinguishing feature of all malignant solid formations is the presence of contrast. As a rule, ultrasound, magnetic resonance and computed tomography are used to diagnose and characterize various kidney formations. Most of these can be accurately diagnosed using a variety of imaging modalities. Ultrasound with a contrast fluid may be indicative in particularly difficult cases, for example, in CRF with a contraindication to the use of other contrasts.
3. Imaging on CT and MRI used to clarify the nature of education. It is important to obtain an image of the tumor before and after the injection of contrast. This will allow you to evaluate the contrast on the Hounsfield scale. Indisputable evidence of contrast enhancement is a change in tumor contrast by at least 20 units.

An abdominal CT scan can also diagnose renal cell carcinoma and provide the following additional information:

• about the functioning and structure of the contralateral organ;
• involvement of the venous system in the pathological process;
• the growth of the primary neoplasm with going beyond the boundaries of the organ;
• an increase in regional lymph nodes;
• state of the liver and adrenal glands.

To obtain data on the blood supply to the kidneys, CT angiography is performed using a contrast agent. If this information is not enough, you can resort to MRI and get the following information:

• determine the contrast of renal neoplasms;
• examine the malignancy in detail;
• assess the degree of damage to the venous system.

Important: MRI is indicated for patients with an allergic reaction to intravenous contrast agents, as well as for pregnant women with preserved kidney function.

Other studies

Renal cavography and arteriography are used only as additional diagnostic methods in patients with specific indications. In patients with symptoms of decreased functioning of the organ, the question of the need for isotope renography should be raised. They also have a complete assessment of kidney function. This will optimize treatment and preserve the functions of the organ.

Other non-standard research methods include PET - positron emission tomography. The true value of this technique, used to diagnose RCC and monitor the progression of the disease, has not yet been fully established.

If metastases to other organs are suspected, computed tomography of the chest is performed. This is the most accurate way to diagnose lung metastases. If computed tomography is not available for any reason, at least a chest x-ray should be performed.

Analysis algorithm

When identifying any renal neoplasms, it is important to adhere to the following analysis algorithm:

• It is important to find out whether this formation is cystic or not.
• If this is not a cystic neoplasm, it is necessary to clarify the presence of macroscopic fat inclusions. If they are, it is more characteristic of angiopyolipomas.
• It is important to rule out kidney cancer that masquerades as an infectious disease or heart attack.
• It is necessary to exclude metastatic lesions of the organ and lymphoma.

Classification

Another technique for assessing solid renal formations is to determine their shape. All solid neoplasms are divided into:

• Bean-shaped - these formations practically do not deform the contour of the organ. Usually they are localized in the renal parenchyma. Such tumors are poorly visualized and are usually completely invisible on CT without the use of contrast.
• Spherical - most common. Usually these are extensive tumors that significantly deform the contours of the organ. Typical representatives of this type include renal cell carcinoma and oncocytoma.

The most important indicator of the malignancy of a tumor is its size. But it is also important to take into account the histological assessment of education. The risk of metastasis formation is directly related to the size of the tumor.

Important: if the size of the neoplasm is not more than 3 cm, then the risk of metastases is small.

By the way, most kidney tumors are no more than four centimeters in size. That is why many of them belong to the group of poorly differentiated renal cell carcinomas. These are painful malignant or benign kidney growths. Surgically removed tumors 10-20 mm in size are benign in most cases (56%), and only in 13% of cases, when a tumor 60-70 mm in size is removed, their benign nature is confirmed.

Biopsy and histology

The main purpose of a biopsy is to determine the malignancy of the tumor, its type and differential grade. Performing a percutaneous biopsy is indicated in such cases:

• in the presence of large formations in the organ that are subject to nephrectomy;
• patients with metastases before systemic therapy.

Histological examination is performed after a biopsy of the tumor tissue or after its surgical removal. There are three histological subtypes:

• papillary occurs in 15% of cases;
• clear cell is diagnosed in almost 90% of cases;
• chromophobic is determined in 5% of patients.

All these histological types differ in molecular genetic changes and histological criteria. Worldwide, there has been an increase in the number of asymptomatic tumors that are incidentally diagnosed during research for another disease. Despite this, many patients with RCC have all the clinical symptoms, so timely diagnosis and treatment of these renal diseases will prolong and save the life of the patient.

Cystic-solid brain tumor is a mixed type. It consists of a single, encapsulated soft node of tumor cells, inside which are numerous smooth-walled cysts.

Causes of a tumor

The key reason for the development of cystic-solid tumors, as well as other neoplasms of the brain, is the impact on the human body of various carcinogenic factors, which should include:

• ionizing radiation;
• excessive exposure to sunlight;
• industrial contact with carcinogens (asbestos, acrylonitrile, benzene, benzidine-based dyes, vinyl chloride, coal and petroleum tar, phenol formaldehyde, etc.);
• oncogenic viruses (adenoviruses, herpes virus, retroviruses).

In some cases, neoplasms can have a hereditary etiology and develop as a result of genetic mutations.

Consequences of a cystic-solid tumor of the brain

A direct consequence of the developed neoplasm is compression (squeezing) of the surrounding tissues and cells, which, in turn, can lead to complete desensitization of the limbs, disruption of the gastrointestinal tract, and urinary organs. The complications that develop after treatment (radiation and chemotherapy) can also be considered a consequence of the impact of the tumor.

Tumor treatment

Operable neoplasms are treated through surgery. This method is complicated by the fact that complete removal of the tumor is required in order to avoid possible relapses, therefore, during the operation, some healthy cells are also removed. In recent years, less invasive methods of performing such interventions using ultrasound and laser technology have been actively introduced into neurosurgical practice. Removal of a solid node of the neoplasm is combined with aspiration of the contents of cysts, the walls of which may not require removal.

If the tumor is inoperable, then the following methods are used:

• symptomatic pharmacotherapy (its goal is to improve the general condition of the patient and level the vivid symptoms of the disease);
• radiation therapy;
• chemotherapy.

Gynecology: textbook / B. I. Baisova and others; ed. G. M. Savelyeva, V. G. Breusenko. - 4th ed., revised. and additional - 2011. - 432 p. : ill.

Chapter 16. OVARIAN DISEASES

Chapter 16. OVARIAN DISEASES

The most common diseases of the ovaries include tumor-like formations and tumors, purulent processes are less common (see the chapter "Inflammatory diseases of the female genital organs").

Tumor-like formations are cysts, the liquid content of which stretches the walls without proliferation of cellular elements. In true ovarian tumors, cell proliferation is observed.

16.1. Tumor-like formations of the uterine appendages

Tumor-like formations include ovarian retention cysts: follicular (73%), corpus luteum cysts (5%), tecalutein (2%), endometrioid (10%), paraovarian (10%).

Cysts are not capable of proliferation, are formed as a result of retention of excess fluid in preformed cavities and cause a significant increase in the ovary. They can be formed from the follicle, corpus luteum, paraovary (epioophoron), endometrioid heterotopias implanted on the surface of the ovary (see "Endometriosis").

Cysts are observed mainly in the reproductive period, but are possible at any age, even in newborns. The frequency of cysts in postmenopausal women is 15%.

The formation of ovarian cysts is promoted by dishormonal, inflammatory and other processes leading to congestive hyperemia of the pelvic organs.

Follicular cysts arise due to the accumulation of fluid in the cystic-atretic follicle as a result of hormonal disorders.

Follicular cysts occur in women with endocrine-metabolic disorders that contribute to the development of hyperestrogenism and chronic anovulation (single-phase menstrual cycle). They occur mainly in the reproductive age, in rare cases they can occur in postmenopausal women, even less often in fetuses and newborns. A sign of the transition of the physiological process of maturation of the follicle into a pathological follicular cyst is the diameter of the liquid formation of more than 30 mm. Fluid accumulates in the cavity of the cyst as a result of extravasation from the blood vessels or due to its continued secretion by the granulosa epithelium.

Morphologically, a follicular cyst is a thin-walled liquid formation, the wall of which consists of several layers of follicular epithelium. Outside of the follicular epithelium is fibrous connective tissue. As the cyst grows, the follicular epithelium undergoes dystrophic changes, becomes thinner, desquamated, and undergoes atrophy. The cyst wall may consist only of connective tissue lined from the inside with flat or cubic cells; in most cases, these cysts are single-chamber. In the ovary, several cysts can occur simultaneously, which, gradually increasing, merge with each other, and therefore the impression of a multi-chamber formation is created.

Macroscopically, follicular cysts are small (50-60 mm in diameter), smooth and thin-walled formations containing a clear light yellow liquid.

Clinically, follicular cysts in most cases do not manifest themselves in any way. In some cases, there is a delay in menstruation, pain of varying intensity in the lower abdomen is possible. Usually, pain appears during the formation of a cyst.

Complications include torsion of the cyst stem, rupture of the cyst wall, or hemorrhage into the formation cavity. Clinically, these complications are manifested by severe pain in the lower abdomen, accompanied by nausea, vomiting. Torsion of the cyst stem leads to an increase in formation as a result of impaired venous circulation, tissue edema and hemorrhage (see Chapter 17 "Acute abdomen" in gynecology ").

During a gynecological examination, the follicular cyst is palpable on the side or anterior to the uterus, elastic consistency, often one-sided, rounded, with a smooth surface, 5-6 cm in diameter, mobile, painless. Bilateral follicular cysts are often the result of ovarian hyperstimulation during infertility treatment.

The diagnosis of ovarian cysts is established on the basis of the clinical picture and dynamic ultrasound with color doppler and laparoscopy.

Follicular cysts on echograms are single-chamber formations of a rounded shape, located mainly on the side or posterior to the uterus. The inner surface of the cyst is even, smooth, its wall is thin (up to 2 mm), the contents are anechoic, with a high level of sound conduction. Often, in patients of active reproductive age, an area of ​​intact ovarian tissue is visualized on the side of the follicular cyst. Behind the formation, an acoustic amplification effect is always noted. The diameter of the cysts varies from 2.5 to 6 cm (Fig. 16.1).

Dynamic ultrasound can differentiate a follicular cyst from a smooth-walled serous cystadenoma.

With CDI in the follicular cyst, single areas of blood flow are detected, located exclusively along the periphery of the formation, with a low speed and medium resistance (IR - 0.4 and higher).

With an uncomplicated cyst, observation of the patient for 6-8 weeks and anti-inflammatory or (according to indications) hormonal therapy are indicated.

Rice. 16.1. Follicular ovarian cyst. ultrasound

fia. Follicular cysts undergo gradual regression and usually disappear within 1-2, less often 3 menstrual cycles.

With the ineffectiveness of conservative treatment or the occurrence of complications, surgical treatment is indicated. With follicular cysts, the method of choice is laparoscopic access, in which, if the preserved ovarian tissue is not changed, the cyst is husked or the tumor-like formation is removed (Fig. 16.2).

After surgical treatment, therapy aimed at normalizing menstrual function, cyclic vitamin therapy (folic acid, ascorbic acid, vitamin E), drugs of the nootropic group (piracetam) and contraceptive drugs for 3 months are recommended. In the perimenopausal period, the uterine appendages are removed on the side of the cyst.

The prognosis is favorable.

Rice. 16.2. Follicular ovarian cyst. Laparoscopy

Cyst of the corpus luteum occurs due to the accumulation of fluid in the place of the burst follicle, sometimes it may contain blood. Such cysts occur only with a two-phase menstrual cycle. It is believed that these cysts are formed as a result of impaired lymph and blood circulation in the corpus luteum; they meet at the age of 16 to 45 years.

Microscopically, luteal and thecalutein cells are detected in the wall of the corpus luteum cyst.

Clinically, the cyst usually does not manifest itself. The menstrual cycle is rarely disturbed. There are no specific clinical signs. In some observations, at the time of the onset of a cyst, pain in the lower abdomen may be noted.

The most common complication is hemorrhage into the cyst cavity, more often in the stage of development of the corpus luteum. Bleeding can be intense and accompanied by a clinical picture of "acute abdomen".

In most cases, the corpus luteum cysts undergo regression. The layer of luteal cells is gradually replaced by connective tissue, and the formation can turn into a cyst, the inner surface of which is devoid of epithelial lining.

The diagnosis of a corpus luteum cyst is established on the basis of anamnestic data, the results of a clinical examination, ultrasound and TsDK, laparoscopy.

With a two-handed vaginal-abdominal examination, the corpus luteum cyst is located mainly on the side or posterior to the uterus. It is round in shape, mobile, with a smooth surface, elastic consistency, with a diameter of 3 to 8 cm, can be sensitive to palpation.

The echographic picture of cysts of the corpus luteum is very diverse. The structure of the cyst can be completely homogeneous and anechoic or have a fine or medium mesh structure, and these structures fill the entire cyst or a small part of it. In the cavity of the cyst, multiple irregularly shaped septa are determined, which are displaced during percussion by an ultrasonic education sensor. In a number of observations, dense inclusions of increased echogenicity - blood clots - are visualized in the cyst cavity. On scans, parietal inclusions up to 1 cm in diameter, irregular in shape, are determined; in single observations, a dense formation is in suspension in the cyst cavity. Sometimes the entire cavity of the cyst is filled with echogenic contents (blood), as a result of which the echographic image resembles a tumor. Despite significant differences in the internal structure of the corpus luteum cysts, their sound conductivity is always high (Fig. 16.3).

The CDC allows to exclude points of vascularization in the internal structures of the corpus luteum cysts and thus to conduct a differential diagnosis with ovarian tumors.

In the cyst of the corpus luteum there is an intense blood flow along the periphery (the so-called coronary) with low vascular resistance (IR<0,4), что нередко напоминает злокачественную неоваскуляризацию (рис. 16.4).

To eliminate errors, dynamic ultrasound with color flow is necessary in the 1st phase of the next menstrual cycle. With a cyst of the corpus luteum, observation is indicated for 1-3 menstrual cycles, since its reverse development is not excluded. Otherwise, surgical treatment is indicated -

Rice. 16.3. Cyst of the corpus luteum with hemorrhage into the cavity. ultrasound

Rice. 16.4. Yellow cyst. ultrasound, power doppler

removal (enucleation) of a cyst within healthy ovarian tissue by laparoscopic access. Retention cysts are usually small, with a thin transparent wall through which homogeneous contents shine through. Several small cysts may be seen on laparoscopy. With side illumination, the retention formations acquire a uniform bluish tint.

The data of ultrasound with CFD, CT, MRI for retention formations in the description of their shape, size, structure and location are the same. When using methods with contrasting, retention formations do not accumulate a contrast agent, and this is a differential diagnostic sign of a cyst, indicating a retention space-occupying formation.

The prognosis is favorable.

Paraovarian cysts located between the sheets of the broad ligament of the uterus. They arise from the rudiments of the mesonephric duct, the oophoron, and also from the coelomic epithelium. Paraovarian cysts make up from 8 to 16.4% of all ovarian formations. These cysts are diagnosed mainly between the ages of 20 and 40, but can occur in girls, as well as at puberty. In childhood and adolescence, paraovarian cysts sometimes have papillary growths on the inner surface. Cysts can be either small (5-6 cm) or giant, occupying the entire abdominal cavity.

Macroscopically, the paraovarian cyst has a round or oval shape, a tight-elastic consistency, with a transparent liquid content. The formation is usually single-chamber, located mainly on the side and above the uterus. The wall of the paraovarian cyst is thin (1-2 mm), transparent, with a vascular network consisting of vessels of the mesentery of the fallopian tube and the cyst wall. As a rule, an elongated, deformed fallopian tube is located along the upper pole of the formation. The ovary is located at the posterior inferior pole of the cyst, sometimes along its lower surface. The contents of the cyst are mostly homogeneous - a clear watery liquid. The wall consists of connective tissue and muscle bundles, from the inside the cyst is lined with cylindrical ciliated, cubic and flat single-row or multi-row epithelium.

A small paraovarian cyst at first does not have a “leg”, but as it grows, one of the sheets of the broad ligament of the uterus protrudes and a cyst stem forms. The composition of such a "leg" may include the fallopian tube, and sometimes the ovary's own ligament.

Clinically, paraovarian cysts often do not manifest themselves. As the cyst grows, the patients complain of pain in the lower abdomen, an increase in the abdomen. Rarely, menstrual irregularities and infertility have been reported.

A complication of a paraovarian cyst may be the torsion of its “legs” with the development of clinical symptoms of an “acute abdomen”.

Verification of the paraovarian cyst presents significant difficulties. With a two-handed gynecological examination on the side and above the uterus, a formation with a diameter of 5 to 15 cm, an elastic consistency, limited mobility, painless, with a smooth, even surface, is determined.

The main and practically the only ultrasonic a sign of paraovarian cysts is the visualization of a separate ovary (Fig. 16.5). The paraovarian cyst is round or oval, the wall is thin (about 1 mm). Education is always single-chamber. The contents of the cysts are mostly homogeneous and anechoic; in some cases, a fine suspension can be determined.

In single observations, parietal growths are visualized on the inner surface of the cyst wall. In CDC, the paraovarian cysts are avascular.

Since paraovarian cysts are observed in young patients, operative laparoscopy is preferable to prevent adhesions. With an uncomplicated cyst, the operation is reduced to its enucleation

Rice. 16.5. Paraovarian cyst. ultrasound

with a dissection of the leaf of the broad ligament of the uterus (preferably in front). In this case, the ovary and fallopian tube are preserved. The fallopian tube shrinks and restores its original shape. Relapses are not noted. The prognosis is favorable.

For endometrioid cysts, see Chapter 13, Endometriosis.

16.2. Tumors of the ovaries

Morphology ovarian tumors are very diverse. This is primarily due to the fact that the ovaries (unlike other organs) do not consist of two components - parenchyma and stroma, but of many elements of different histogenesis. There are many tissue variants that provide the main functions of this organ: the maturation of germ cells and the production of sex hormones (integumentary epithelium, egg and its embryonic and mature derivatives, granulosa cells, leaky tissue, hilus cells, connective tissue, blood vessels, nerves, etc.) . In the origin of ovarian tumors, an important role is played by rudiments preserved from the period of embryogenesis. Many tumors develop from postnatal areas of the epithelium, growths subject to metaplasia and paraplasia, in particular from the epithelium of the fallopian tubes and uterus, which can implant on the surface of the ovary.

Some ovarian tumors develop from the epithelium, which is capable of submerged growth, from which sex cord tumors are formed: granulosa cell tumors, thecomas, androgen-producing tumors (androblastomas) from the remnants of the male part of the gonad.

Risk factors in relation to the occurrence of ovarian tumors, ways to prevent this disease are determined. These include: early or late menarche, late (after 50 years) onset of menopause, menstrual irregularities. At risk for ovarian cancer

associated with reduced reproductive function of women, infertility, non-carrying. Chronic inflammatory diseases of the uterine appendages can form a premorbid background of the tumor process.

Great importance in etiology and pathogenesis ovarian tumors are attributed to genetic factors, neurohumoral and endocrine disorders.

Due to the diversity of cellular elements of ovarian tumors, there are many classifications of which the most acceptable are those based on microscopy of the ovarian mass. In modern gynecology, a histological classification of ovarian tumors is used (WHO, 1973). In clinical practice, a simplified scheme of the most common variants of ovarian formations can be used. The scheme is based on the microscopic characteristics of tumors, taking into account the clinical course of the disease. Depending on the cellular composition, ovarian formations are divided into:

epithelial tumors;

Sex cord stromal tumors;

germ cell tumors;

Rare tumors;

Tumor processes.

All variants of tumors are divided into benign, borderline (low-grade ovarian tumors) and malignant. The classification takes into account one of the most important features of ovarian tumors - often cancer develops against the background of previous benign ovarian tumors.

Variants of the most common ovarian tumors

I. Tumors of the surface epithelium and stroma of the ovaries (cystadenomas).

Serous tumors:

Simple serous cystadenoma;

Papillary (rough papillary) serous cystadenoma;

Papillary cystadenoma.

Mucinous tumors:

Pseudomucinous cystadenoma.

Endometrioid tumors (see Chapter 13 "Endometriosis").

Brenner tumors.

Ovarian cancer.

II. Tumors of the sex cord and stroma of the ovary.

Granulostromal cell tumors:

granulosa cell tumor;

Tekoma;

Fibroma.

Androblastomas.

III. germ cell tumors.

Dysgerminoma.

Teratomas:

mature;

Immature.

Epithelial ovarian tumors

The largest group of benign epithelial ovarian tumors are cystadenomas (former name - cystomas). Depending on the structure of the epithelial lining and the internal contents of cystadenomas are divided into serous and mucinous.

Serous tumors account for 70% of all epithelial neoplasms of the ovaries. They are divided into simple serous (smooth-walled) and papillary (papillary).

Simple serous cystadenoma (smooth-walled cilioepithelial cystadenoma, serous cyst; rice. 16.6) - a true benign tumor of the ovary. Serous cystadenoma is covered with low cuboidal epithelium, under which there is a connective tissue stroma. The inner surface is lined with ciliated epithelium, resembling tubal, capable of proliferation.

Microscopically, a well-differentiated epithelium is determined, resembling that in the fallopian tube and capable of becoming indifferent, flattened-cubic in formations stretched with contents. The epithelium in some areas may lose cilia, and in some places even be absent, sometimes it undergoes atrophy and desquamation. In such situations, morphologically smooth-walled serous cystadenomas are difficult to distinguish from functional cysts. In appearance, such a cystadenoma resembles a cyst and is called serous. Macroscopically, the surface of the tumor is smooth, the tumor is located on the side of the uterus or

Rice. 16.6. Smooth-walled (simple serous) ovarian cystadenoma. Stained with hematoxylin and eosin, χ 400. Photo by O.V. Zayratyan

in the back vault. More often the tumor is unilateral, single-chamber, ovoid shape, tight elastic consistency. Cystadenoma does not reach large sizes, mobile, painless. Usually the content of the tumor is represented by a clear straw-colored serous fluid. Simple serous cystadenoma turns into cancer very rarely.

Papillary (rough papillary) serous cystadenoma - a morphological variety of benign serous cystadenomas, is observed less frequently than smooth-walled serous cystadenomas. It makes up 7-8% of all ovarian tumors and 35% of all cystadenomas. The tumor has the appearance of a single or multi-chamber cystic neoplasm, on the inner surface of which there are single or numerous dense papillary vegetations on a wide base, whitish in color.

The structural basis of the papillae is small-celled fibrous tissue with a small number of epithelial cells, often with signs of hyalinosis. The integumentary epithelium is similar to the epithelium of smooth-walled cylioepithelial cystadenomas. Rough papillae are an important diagnostic feature, since similar structures are found in serous cystadenomas and are never seen in non-neoplastic ovarian cysts. Gross papillary growths with a high degree of probability make it possible to exclude the possibility of malignant tumor growth already during an external examination of the surgical material. Degenerative changes in the wall can be combined with the appearance of layered petrificates (psammoma bodies - Fig. 16.7).

Rice. 16.7. Papillary serous cystadenoma. Stained with hematoxylin and eosin, χ 120. Photo by O.V. Zayratyan

papillary serous cystadenoma has the greatest clinical significance due to its pronounced malignant potential and high incidence of cancer. The frequency of malignancy reaches 50%.

A significant difference between papillary serous cystadenoma and rough papillary cystadenoma is the ability of the integumentary epithelium to proliferate briskly, creating more or less mature structures. Papillary growths of a soft consistency often merge with each other and are unevenly located on the walls of individual chambers. Papillae can form large nodes that invert tumors. Multiple papillae can fill the entire tumor capsule, sometimes grow through the capsule to the outer surface. The tumor takes on the appearance of a cauliflower, raising suspicion of a malignant growth.

Papillary cystadenomas can spread over a large area, disseminate throughout the peritoneum, and lead to ascites.

The tumor is limitedly mobile, with a short stalk, often bilateral, sometimes located intraligamentally. The occurrence of ascites is associated with the growth of papillae on the surface of the tumor, along the peritoneum and a violation of the resorptive capacity of the peritoneum of the uterine-rectal space. Eververting papillary cystadenomas are much more likely to be bilateral; in this case, the course of the disease is more severe. With this form, ascites is 2 times more common. All this makes it possible to consider an everting papillary tumor clinically more severe than an inverting one.

Borderline papillary cystadenoma (low grade) has more abundant papillary growths with the formation of extensive fields. Microscopically determined nuclear atypism and increased mitotic activity. The main diagnostic criterion is the absence of invasion into the stroma, but deep intussusceptions can be determined without germination of the basement membrane and without pronounced signs of atypism and proliferation.

The most serious complication of papillary cystadenoma is its malignancy - the transition to cancer.

Mucinous cystadenoma (pseudomucinous cystadenoma) ranks second in frequency (after cilioepithelial tumors) and is a benign neoplasm of the ovary (formerly called pseudomucinous tumor)

The tumor is detected in all periods of life, more often in postmenopausal. It is covered with low cuboidal epithelium. The underlying stroma in the wall of mucinous cystadenomas is formed by fibrous tissue of various cell densities, the inner surface is lined with high prismatic epithelium with light cytoplasm, which is generally very similar to the epithelium of the cervical glands.

Mucinous cystadenomas are almost always multilocular. The chambers are filled with mucous content, which is a mucin containing glycoproteins and heteroglycans. True mucinous cystadenomas do not have papillary structures. The dimensions of the mucinous cystadenoma are usually significant, there are also gigantic ones, with a diameter of 30-50 cm.

the outer and inner surfaces of the walls are smooth. The walls of a large tumor are thinned and can even be translucent due to significant stretching. The contents of the chambers are mucous or jelly-like, yellowish, less often brown, hemorrhagic.

The epithelium lining the border cystadenomas is characterized by polymorphism and hyperchromatosis, as well as increased mitotic activity of the nuclei (Fig. 16.8). Borderline mucinous cystadenoma differs from mucinous carcinoma in that it does not invade the tumor epithelium.

Rare epithelial ovarian formations include pseudomyxoma of the ovary and peritoneum, Brenner's tumor.

Pseudomyxoma of the ovary and peritoneum - a type of mucinous tumor originating from mucinous cystadenomas, cystadenocarcinomas, and also from diverticula of the appendix. The development of pseudomyxoma is associated with a rupture of the wall of a mucinous ovarian tumor or with impregnation of the entire thickness of the wall of the tumor chamber without a visible rupture. In most cases, the disease occurs in women over 50 years of age. There are no characteristic symptoms, the disease is almost not diagnosed before the operation. In fact, it is possible to talk about a malignant or benign variant of pseudomixomas, since they do not infiltrate and do not grow into tissues.

Mucin is distributed in the abdominal cavity between the loops of the intestines. Under microscopic examination, individual epithelial cells are difficult to find. Pseudomyxoma often leads to depletion of the body and death.

The treatment is surgical, it consists in removing the mucin, but the process often recurs, and the mucin accumulates again.

Rice. 16.8. Mucinous cystadenoma of the ovary. Stained with hematoxylin and eosin, χ 120. Photo by O.V. Zayratyan

Brenner tumor (fibroepithelioma, mucoid fibroepithelioma) - fi-

broepithelial tumor, including cells of the stroma of the ovary.

Recently, the origin of the tumor from the integumentary coelomic epithelium of the ovary and from the chyle has been increasingly substantiated. The incidence of benign Brenner tumors is about 2% of all ovarian tumors. It occurs both in early childhood and in women over 50 years of age. The tumor has a solid structure in the form of a dense knot, the cut surface is grayish-white, with small cysts.

Macroscopically, there can be both cystic and cystic-solid structures. On section, the cystic part of the tumor is represented by multiple chambers with liquid or mucous contents. The inner surface may be smooth or with a tissue resembling papillary growths, loose in places.

The microscopic picture of the Brenner tumor is represented by epithelial nests surrounded by cords of spindle-shaped cells. Cellular atypism and mitoses are absent. Brenner's tumor is often associated with other ovarian tumors, especially mucinous cystadenomas and cystic teratomas. The possibility of developing proliferative forms of Brenner's tumor and malignancy is not excluded.

The size of the tumor - from microscopic to the size of the head of an adult. The tumor is unilateral, often left-sided, round or oval in shape, with a smooth outer surface. The capsule is usually absent. In appearance and consistency, the tumor often resembles an ovarian fibroma.

Mixed epithelial tumors characterized by a combination of serous and mucinous epithelial structures.

Macroscopically, mixed tumors are multi-chamber formations with different contents. There are serous, mucinous contents, less often areas of a solid structure, sometimes resembling fibroma or papillary growths.

Clinical symptoms epithelial ovarian tumors. Benign ovarian tumors, regardless of the structure in clinical manifestations, have many similarities. Ovarian tumors often occur asymptomatically in women older than 40-45 years. There are no specific clinical symptoms of any tumor. However, with a directed questioning of the patient, complaints of dull, aching pains of varying severity in the lower abdomen, in the lumbar and inguinal regions can be identified. Pain often radiates to the lower extremities and the lumbosacral region, may be accompanied by dysuric phenomena, apparently caused by the pressure of the tumor on the bladder, an increase in the abdomen. As a rule, pain is not associated with the menstrual cycle. Paroxysmal or sharp pains are caused by torsion of the tumor stem (partial or complete) or perforation of the tumor capsule (see "Acute abdomen" in gynecology).

At papillary serous pain in cystadenomas occurs earlier than in other forms of ovarian tumors. Apparently, this is due to the anatomical features of papillary ovarian tumors (bilateral process, papillary growths and adhesions in the pelvis).

With papillary cystadenomas, more often bilateral, ascites is possible. The most serious complication of papillary cystadenoma remains malignancy.

With large tumors (often mucinous), there is a feeling of heaviness in the lower abdomen, the abdomen itself increases, the function of neighboring organs is disturbed (constipation, dysuric phenomena appear). Reproductive function is impaired in every 5th examined (primary or secondary infertility).

The second most common complaint is menstrual irregularity; it is possible from the moment of menarche or occurs later.

Diagnostics epithelial tumors of the ovary. Despite technological progress, diagnostic thinking based on vaginal and recto-abdominal examination has not lost its importance. With a two-handed gynecological examination, it is possible to identify a tumor and determine its size, consistency, mobility, sensitivity, location in relation to the pelvic organs, and the nature of the surface of the tumor. A tumor that has reached a certain size is palpated (when the volume of the ovary increases due to the tumor). With small tumor sizes and (or) with giant tumors and an atypical location of the formation, a bimanual study is uninformative. It is especially difficult to diagnose ovarian tumors in obese women and in patients with adhesive process in the abdominal cavity after previous abdominal surgery. It is not always possible to judge the nature of the tumor process according to palpation data. Bimanual examination gives only a general idea of ​​the pathological formation in the small pelvis. Recto-vaginal examination helps to exclude malignancy, in which it is possible to determine the absence of "thorns" in the posterior fornix, overhanging of the fornix with ascites, and germination of the rectal mucosa.

Bimanual vaginal-abdominal examination in patients with simple serous cystadenoma in the area of ​​the uterine appendages, a volumetric formation is determined posteriorly or to the side of the uterus, round, more often ovoid, of a tight elastic consistency, with a smooth surface, 5 to 10 cm in diameter, painless, mobile on palpation.

Papillary cystadenomas more often they are bilateral, located on the side or posterior to the uterus, with a smooth and (or) uneven (hilly) surface, rounded or ovoid shape, tight elastic consistency, movable or limited movable, sensitive or painless on palpation. The diameter of the neoplasms ranges from 7 to 15 cm.

With a two-handed gynecological examination mucinous cystadeno-ma is determined posterior to the uterus. Education with a bumpy surface, uneven, often tight-elastic consistency, rounded shape, limited mobility, diameter from 9 to 20 cm or more, the tumor is sensitive to palpation.

With a two-handed vaginal-abdominal examination in patients with a verified diagnosis Brenner tumors on the side and posterior to the uterus, a volumetric formation of an ovoid or (more often) rounded shape, dense consistency, with a smooth surface, 5-7 cm in diameter, is determined;

visible, painless. Brenner's tumor often resembles subserous uterine myoma.

Ultrasound occupies one of the leading places among the methods for diagnosing pelvic tumors due to its relative simplicity, accessibility, non-invasiveness and high information content.

Sonographically smooth-walled serous cystadenoma has a diameter of 6-8 cm, rounded shape, the thickness of the capsule is usually 0.1-0.2 cm. The inner surface of the tumor wall is smooth, the content of cystadenomas is homogeneous and anechoic, septa can be visualized, often single. Sometimes a finely dispersed suspension is determined, which is easily displaced during percussion of the formation. The tumor is usually located posterior and lateral to the uterus

(Fig. 16.9).

have papillary growths unevenly located on the inner surface of the capsule in the form of parietal structures of various sizes and increased echogenicity. Multiple very small papillae roughen or spongy the wall. Sometimes lime is deposited in the papillae; on scans, it is of increased echogenicity. In some tumors, papillary growths fill the entire cavity, creating the appearance of a solid area. Papillae can grow on the outer surface of the tumor. The thickness of the capsule of papillary serous cystadenoma is 0.2-0.3 cm. Papillary serous cystadenomas are defined as bilateral rounded, less often oval formations with a diameter of 7-12 cm, single-chamber and (or) two-chamber. They are located on the side or posterior to the uterus, sometimes thin linear septa are visualized (Fig. 16.10).

Mucinous cystadenoma has multiple partitions 0.2-0.3 cm thick, often in separate areas of cystic cavities. Suspension is visualized only in relatively large formations. Mucinous cystadenoma is often large, >20 cm in diameter (sometimes up to 50 cm), almost always multi-chamber, located mainly on the side and behind the uterus,

Rice. 16.9. Simple serous ovarian cystadenoma.

ultrasound

Fig.16.10.Papillaryse-

pink cystadenoma of the ovary. ultrasound

round or ovoid shape. In the cavity, a finely dispersed suspension of medium or high echogenicity that is not displaced by percussion with an ultrasonic sensor is visualized. The contents of some chambers may be homogeneous (Fig. 16.11).

Brenner tumor, mixed, undifferentiated tumors give a non-specific image in the form of formations of a heterogeneous solid or cystic-solid structure.

CDC helps more accurately. differentiate benign and malignant ovarian tumors. According to the curves of blood flow velocities in the ovarian artery, the pulsation index and IR, malignancy of tumors can be suspected, especially in the early stages, since malignant tumors are characterized by active vascularization, and the absence of vascularization zones is more typical of benign neoplasms. At the CDC, good

Rice. 16.11. Mucinous cystadenoma of the ovary. Ultrasound, power doppler

High-quality epithelial ovarian tumors are characterized by moderate vascularization in the capsule, septa, and echogenic inclusions. IR does not exceed 0.4.

The use of ultrasound scanners that provide a three-dimensional reconstruction (3D) of the acoustic picture makes it possible to visualize the vascular bed of the ovarian formation in more detail, to assess the depth and spatial relationship of normal and pathological structures.

CT and MRI are used to diagnose ovarian tumors.

Endoscopic research methods (laparoscopy) are widely used for the diagnosis and treatment of ovarian tumors. Although laparoscopy does not always allow to determine the internal structure and nature of the formation, it can be used to diagnose small ovarian tumors that do not lead to volumetric transformation of the ovaries, "non-palpable ovaries" (Fig. 16.12).

Laparoscopic intraoperative diagnosis of ovarian tumors is of great value. The accuracy of laparoscopic diagnosis of tumors is 96.5%. The use of laparoscopic access is not indicated in patients with malignant ovarian tumors, which determines the need to exclude malignancy before surgery. If malignant growth is detected during laparoscopy, it is advisable to proceed to laparotomy (conversion), since laparoscopic removal of a cystadenoma with malignant degeneration may violate the integrity of the tumor capsule and colonize the peritoneum, and difficulties may arise when removing the omentum (omentectomy).

In the diagnosis of ovarian tumors, a large place is given to the determination of specific biological substances by biochemical and immunological methods. Of greatest interest are numerous tumor-associated markers - tumor-associated antigens (CA-125, CA-19.9, CA-72.4).

Rice. 16.12. Simple serous cystadenoma. Laparoscopy

The concentration of these antigens in the blood makes it possible to judge the processes in the ovary. CA-125 is found in 78-100% of patients with ovarian cancer, especially in serous tumors. Its level exceeds the norm (35 IU / ml) only in 1% of women without tumor pathology of the ovaries and in 6% of patients with benign tumors. Tumor markers are used in the dynamic monitoring of patients with malignant ovarian tumors (before, during and after treatment).

In case of bilateral lesions of the ovaries, an X-ray examination of the gastrointestinal tract is performed to exclude a metastatic tumor (Krukenberg), if necessary, endoscopic methods (gastroscopy, colonoscopy) are used.

Additional research methods in patients with ovarian masses allow not only to determine the surgical access, but also to form an opinion about the nature of the mass formation, which determines the choice of the method of surgical treatment (laparoscopy-laparotomy).

Treatmentepithelial tumors operational. The volume and access of surgical intervention depend on the age of the patient, the size and malignancy of the formation, as well as on concomitant diseases.

The volume of surgical treatment helps to determine an urgent histological examination. At simple serous cystadenoma at a young age, exfoliation of the tumor is acceptable, leaving healthy ovarian tissue. In older women, the uterine appendages on the affected side are removed. At Borderline type simple serous cystadenoma (low grade) in women of reproductive age, the tumor is removed on the affected side with a biopsy of the collateral ovary and omentectomy. In patients of premenopausal age, supravaginal amputation of the uterus and (or) extirpation of the uterus with appendages and omentectomy are performed.

Papillary cystadenoma due to the severity of proliferative processes, it requires a more radical operation. With the defeat of one ovary, if the papillary growths are located only on the inner surface of the capsule, in a young woman, removal of the appendages on the affected side and a biopsy of the other ovary are acceptable (Fig. 16.13). If both ovaries are affected, supravaginal amputation of the uterus with both appendages is performed.

If papillary growths are found on the surface of the capsule, at any age, supravaginal amputation of the uterus with appendages or extirpation of the uterus and removal of the omentum are performed.

It is possible to use laparoscopic access in patients of reproductive age with unilateral ovarian lesion without germination of the tumor capsule using an evacuation bag-container.

At borderline papillary cystadenoma unilateral localization in young patients interested in preserving reproductive function, removal of the uterus on the affected side, resection of the other ovary and omentectomy are acceptable (Fig. 16.14).

In patients of perimenopausal age, the uterus is extirpated with appendages on both sides and the omentum is removed.

Rice. 16.13. Papillary serous cystadenoma of the ovary. Papillary growths on the inner surface of the capsule

Rice. 16.14. Borderline ovarian tumor (serous borderline cystadenopapillomas). Stained with hematoxylin and eosin, χ 200. Photo by O.V. Zayratyan

Treatmentmucinous cystadenoma operative: removal of the appendages of the affected ovary in patients of reproductive age. In pre- and post-menopausal periods, it is necessary to remove the appendages on both sides along with the uterus.

Small mucinous cystadenomas can be removed by surgical laparoscopy using an evacuation bag. For large tumors, it is necessary to first remove the contents with an electric suction through a small hole.

Regardless of the morphological affiliation of the tumor before the end of the operation, it should be cut and examine the inner surface of the tumor.

Also shown is a revision of the abdominal organs (vermiform appendix, stomach, intestines, liver), examination and palpation of the omentum, para-aortic lymph nodes, as in all types of tumors.

The prognosis for surgical treatment of cystadenomas is favorable.

TreatmentBrenner tumors operational. In young patients, removal of the uterine appendages on the affected side is indicated. In perimenopause, supravaginal amputation of the uterus with appendages is performed. With a proliferating tumor, supravaginal amputation of the uterus with appendages and total removal of the omentum are indicated.

Tumors of the sex cord of the ovary and stroma (hormonally active)

Sex cord stromal tumors include granulosastromal cell tumors (granulosa cell tumor and the thecom fibroma group) (Fig. 16.15) and androblastomas, tumors that originate from granulosa cells, theca cells, Sertoli cells, Leydig cells, and ovarian stromal fibroblasts. Hormone-dependent tumors are divided into feminizing (granulosa cell and thecoma) and masculinizing (androblastoma).

Most neoplasms contain cells of the ovarian type (granulosomal cell tumors). A smaller part is represented by derivatives of testicular type cells (Sertoli - stromal cell tumors). If it is impossible to differentiate female and male tumors, the term "unclassifiable tumors of the sex cord and ovarian stroma" can be used.

Sex cord stromal tumors account for about 8% of all ovarian masses.

Feminizing tumors occur at any age: granulosa cell - more often in children and at a young age, thecoma - in pre- and postmenopause and is extremely rare in children.

Granulosa cell tumor makes up from 1 to 4% of hormone-producing ovarian neoplasms, develops from granulosa tissue, similar in structure to the granular epithelium of a maturing follicle; more common in adolescence and reproductive periods. Tekoma consists of cells similar to the theca cells of atretic follicles and is usually observed during peri- and menopause. Granulosa cell tumors account for 1-2% of all ovarian neoplasms. Thecomas are 3 times less common.

Rice. 16.15. Granulosa cell tumor of the ovaries. Stained with hematoxylin and eosin, × 200. Photo by O.V. Zayratyan

Clinical manifestations associated with the hormonal activity of feminizing tumors. Granulosa cell tumor of the "juvenile type" causes premature puberty, which is more correctly considered false due to the lack of ovulation. Girls have irregular spotting from the genital tract with a slight development of secondary sexual characteristics; the features of estrogenic influence are determined - the symptom of the "pupil", the cyanosis of the vulva, the folding of the vagina, the increase in the body of the uterus. Somatic development is not accelerated. Bone age corresponds to the calendar. In reproductive age, dysfunctional uterine bleeding is possible.

Feminizing tumors in the elderly are usually manifested by metrorrhagia, which is a particularly significant symptom of the neoplasm. In the postmenopausal period, the level of estrogen hormones is increased with the "rejuvenation" of the patient. In the endometrium, proliferative processes can be detected: glandular cystic hyperplasia, often with atypia of varying degrees, endometrial polyps, endometrial adenocarcinoma may develop.

Diagnosis established on the basis of a pronounced clinical picture, data from a general examination and gynecological examination, tests of functional diagnostics, hormone levels, ultrasound with color flow, laparoscopy.

Feminizing ovarian tumors two-handed vaginal-abdominal the study are defined as unilateral formations with a diameter of 4 to 20 cm (average 10-12 cm), dense or tight elastic

skoy consistency (depending on the proportion of fibrous or tematous stroma), mobile, smooth-walled, painless.

Granulosa cell tumor has a clear capsule, on the section - pronounced lobulation and yellow color, focal hemorrhages and necrosis fields. At tekoms the capsule is usually absent: the section shows a solid structure, a tissue with a yellowish tinge up to an intense yellow color. Foci of hemorrhage, cysts are not typical. In most cases, thecomas are unilateral and rarely malignant. The diameter ranges from 5 to 10 cm.

On echograms, feminizing tumors are visualized as a unilateral rounded formation with a predominantly echo-positive internal structure and echo-negative inclusions, often multiple. Tumor diameter 10-12 cm.

The tumor may have cystic variants; in such cases, it resembles an ovarian cystadenoma. The sound conduction of tumors is normal. Comparison of anamnestic data, echographic picture with visualized pathology of the endometrium (especially in postmenopausal age) helps to establish the correct diagnosis.

With CDI, multiple zones of vascularization are visualized both in the tumor itself and along its periphery. The internal structures of the formation look like a motley mosaic with a predominance of venous blood flow. In the spectral Doppler study mode, the blood flow in ovarian tumors has a low systolic velocity and low resistance (IR<0,4). Точность диагностики при УЗИ с ЦДК составляет 91,3% (рис. 16.16, 16.17)

Feminizing tumors can be benign (80%) or malignant. Malignancy is determined by metastases and relapses. Metastases occur mainly in the serous cover of the abdominal organs, on the parietal peritoneum and in the omentum. Malignant is more often a granulosa cell tumor, extremely rarely - thecoma.

Treatment feminizing tumors only operational. The volume and access (laparotomy-laparoscopy) depend on the age of the patient, the magnitude

Rice. 16.16. Thecoma of the ovary. Ultrasound, CDC

Rice. 16.17. Granulosa cell tumor. ultrasound,

CDC

formations, the state of the other ovary and concomitant genital and extragenital pathology.

During the operation, an urgent histological examination is carried out, an audit of the abdominal cavity, a collateral ovary is carefully examined. With its increase, a biopsy is indicated, they try to determine the state of the para-aortic lymph nodes.

In girls with a benign granulosa cell tumor, only the affected ovary is removed; in patients of the reproductive period, removal of the uterine appendages on the affected side is indicated. In peri- and post-menopausal age, supravaginal amputation of the uterus with appendages or extirpation of the uterus with appendages is performed (depending on changes in the endometrium). Small tumors can be removed by surgical laparoscopy.

In a malignant tumor (according to the results of an urgent histological conclusion), extirpation of the uterus with appendages on both sides and removal of the omentum are indicated.

Fibroma of the ovary occupies a special place among fibrom-tecomas and develops from connective tissue. Essentially, it is a hormonally inactive thecoma. The structure of the tumor is represented by intertwining bundles of spindle-shaped cells that produce collagen.

Ovarian fibroma is a relatively rare benign tumor. Fibroids make up from 2.5 to 4% of all tumors, occur at any age (more often - at 40-60 years), tumor sizes - from 3 to 15 cm. Before puberty, ovarian fibroma does not occur. Patients have an unfavorable premorbid background with frequent violations of menstrual and generative functions. Perhaps these disorders are due to the same etiological factor that caused the tumor.

Ovarian fibroma is often combined with uterine fibroids. Both fibroma and cyst in the same ovary are not excluded. When combined with other diseases, the clinical picture is determined by the totality of their symptoms.

Ovarian fibroids are often discovered by chance during surgery. Fibroma growth is slow, but with dystrophic changes, the tumor can quickly increase in size.

The tumor does not secrete steroid hormones, but in 10% of cases it may be accompanied by Meigs syndrome (ascites in combination with hydrothorax and anemia). The development of these processes is associated with the release of edematous fluid from the tumor tissue and its entry from the abdominal cavity into the pleural cavities through the hatches of the diaphragm. On section, fibroma tissue is usually dense, white, fibrous, sometimes with areas of edema and cystic degeneration, calcification is possible, sometimes diffuse. The tumor is localized in one ovary in the form of a clearly defined node.

With an increase in mitotic activity, the tumor is classified as borderline with a low malignant potential.

Ovarian fibroma is diagnosed on the basis of the clinical course of the disease and the data of a two-handed vaginal-abdominal examination. The tumor has to be differentiated from a subserous pedunculated myoma node, as well as from tumors of a different structure. Gynecological examination on the side or behind the uterus is determined volume formation with a diameter of 5-15 cm, round or ovoid shape, dense, almost stony consistency, with a smooth surface, mobile, painless. Ovarian fibroma is often accompanied by ascites, so it is sometimes mistaken for a malignant neoplasm.

Diagnosis is aided by ultrasound with CDI. The echograms show a round or oval formation with clear, even contours. The internal structure is predominantly homogeneous, echopositive, of medium or low echogenicity. Sometimes echo-negative inclusions are detected, indicating degenerative changes. Pronounced sound absorption is determined directly behind the tumor. With CDI, the vessels in fibromas are not visualized, the tumor is avascular. The sensitivity and specificity of MRI and CT in the diagnosis of ovarian fibroids are equivalent to those of ultrasound.

At laparoscopy, ovarian fibroma is round or ovoid, with a smooth surface relief and poor vascularization. The capsule is usually whitish, the vessels are determined only in the area of ​​the fallopian tube. A whitish-pink shade of the capsule color is also possible. The consistency of the tumor is dense.

Fibroma treatment is surgical. The volume and access of surgical intervention depend on the size of the tumor, the age of the patient and concomitant gynecological and extragenital diseases. As a rule, the uterine appendages are removed on the affected side in the absence of indications for removal of the uterus in patients of reproductive age. With a small tumor, laparoscopic access is used.

The prognosis is favorable.

Stromal cell tumors (androblastoma, Sertoli tumor). An-

Droblastoma refers to hormonally active masculinizing tumors and accounts for about 1.5-2% of all ovarian neoplasms. It is a masculinizing hormone-producing tumor containing Sertoli-Leydig (hilus and stromal) cells. Formed in excess an-

Drogens inhibit the function of the pituitary gland, and the production of estrogen decreases in the body. The tumor is predominantly benign. Androblastoma occurs in patients under 20 years of age and in girls; in these observations, isosexual precocious puberty is often noted. The diameter of the formation is from 5 to 20 cm. The capsule is often clearly defined, the structure is often lobulated, on the section the tumor is solid, yellowish, orange or orange-gray in color. The preserved other ovary is always atrophic, fibrously altered, as in postmenopausal women.

The main clinical manifestation of the tumor is virilization. Against the background of general health, amenorrhea occurs, infertility is noted, the mammary glands decrease (defeminization), later signs of masculinization appear - the voice coarsens, male-type hair growth (hirsutism) develops, libido increases, the thickness of subcutaneous fatty tissue decreases, clitoral hypertrophy occurs, body contours and faces take on masculine features. Symptoms of the disease usually develop gradually.

Clinical manifestations mainly depend on age. In the reproductive period, the patient goes to the doctor, as a rule, about amenorrhea and infertility. In the period of menopause and postmenopause, in most cases, clinical signs are considered age-related phenomena, and only with the development of masculinization, the patient goes to the doctor. The tumor develops slowly, so an earlier visit to the doctor is usually associated with pain in the lower abdomen (with complications).

The diagnosis is established on the basis of the clinical picture and the data of a two-handed vaginal-abdominal examination, as well as ultrasound with CDI.

In a gynecological examination, the tumor is determined on the side of the uterus, it is one-sided, mobile, painless, with a diameter of 5 to 20 cm, oval in shape, dense in consistency, with a smooth surface. With ultrasound, solid, cystic and cystic-solid types are distinguished. The echographic picture shows a heterogeneous internal structure with multiple hyperechoic areas and hypoechoic inclusions.

Dopplerography has no definite value in determining the morphological structure of the tumor, but sometimes it helps to detect the tumor.

Treatment virilizing tumors of the ovary operatively, both laparotomy and laparoscopic access are used. The volume and access during surgical treatment depend on the age of the patient, the size and nature of the mass formation. With androblastoma in girls and patients of reproductive age, it is sufficient to remove the uterine appendages on the affected side. In postmenopausal patients, supravaginal amputation of the uterus with appendages is performed. After removal of the tumor, the functions of the woman's body are restored in the same sequence in which the symptoms of the disease developed. The appearance of a woman changes very quickly, menstrual and reproductive functions are restored, but the coarsening of the voice, clitoral hypertrophy and hirsutism can remain for life. If a malignant tumor is suspected, panhysterectomy and removal of the omentum are indicated.

The prognosis for a benign tumor is favorable.

germ cell tumors

Germinogenic neoplasms arise from the primary germ cells of the embryonic gonads and their derivatives, from the three germ layers - ectoderm, mesoderm and endoderm.

Dysgerminoma (seminoma of the ovary) - malignant tumor of the ovary, has a strong resemblance to the corresponding testicular tumor. Dysgerminomas account for about 1-2% of ovarian tumors and about 3% of all malignant tumors. They are most often detected at the age of 10 to 30 years (in about 5% of cases up to 10 years and very rarely after 50 years).

Dysgerminoma is the most common malignant tumor in pregnancy. Consists of cells morphologically similar to primordial follicles. It is believed that dysgerminomas originate from primary germ cells. Normally, by the time of birth, all germ cells are part of primordial follicles, germ cells that do not form follicles die. If this does not happen, then germ cells acquire the ability for uncontrolled proliferation and give rise to a tumor. Dysgerminoma occurs in adolescents and young women with general and genital infantilism with late menarche. Anomalies of the external genital organs are often observed. The tumor is usually unilateral.

A typical dysgerminoma is a round or ovoid solid tumor with a smooth whitish fibrous capsule. The tumor can reach a considerable size, completely replacing the ovarian tissue; dysgerminoma with small nodes has a different consistency.

On section, the tumor tissue is yellowish, pale brown with a pink tint. Large tumors are usually mottled due to hemorrhages and necrosis of varying age.

Clinical manifestations have no specific features. Hormonal activity of dysgerminoma is not characteristic.

Complaints of patients are nonspecific, sometimes there are dull pulling pains in the lower abdomen, general malaise, dysuric phenomena, weakness, drowsiness, fatigue, the menstrual cycle is often disturbed: prolonged amenorrhea may be replaced by uterine bleeding. Dysgerminoma is prone to rapid growth, metastatic spread and germination in neighboring organs. Metastasis usually occurs via the lymphogenous route, affecting the lymph nodes of the common iliac artery, the distal abdominal aorta, and the supraclavicular lymph nodes. Hematogenous metastases occur in the terminal stage of the disease, more often in the liver, lungs, bones. The manifestations of dysgerminoma metastases are similar to those of the primary tumor.

Diagnosis are established on the basis of the clinical course of the disease, data from a two-handed gynecological examination, ultrasound with color doppler and morphological examination of a removed macropreparation. In a gynecological examination, the tumor is usually located behind the uterus, often unilateral, rounded, with fuzzy contours, dense, tuberculous

flock, with a diameter of 5 to 15 cm (more often reaches large sizes), in the initial stage, mobile, painless.

Ultrasound with CDC is of great help. On echograms, the tumor has an echo-positive medium echogenicity, often a lobular structure. Inside the neoplasm, areas of degenerative changes are not uncommon, the contours are uneven, the shape is irregular.

Doppler examination reveals multiple areas of vascularization both along the periphery and in the central structures of the tumor: with low IR (<0,4).

Treatment dysgerminomas only surgically followed by radiation therapy. It is advisable to use laparotomy access. With a unilateral tumor without signs of spread beyond the affected ovary in young women who plan to have children in the future, it can be limited to the removal of the uterine appendages on the affected side. In patients of perimenopausal age, extirpation of the uterus with appendages is performed, and the omentum is removed. During the operation, the integrity of the capsule should not be violated, as this significantly worsens the prognosis.

When the tumor spreads beyond the ovary, a more radical operation is indicated - removal of the uterus with appendages and omentum, followed by radiotherapy. Enlarged lymph nodes are subject to removal, and their area - X-ray therapy. Both the primary tumor and metastatic nodes respond well to radiotherapy. Pure forms of dysgerminomas are highly sensitive to radiation therapy, which determines a relatively favorable prognosis of the disease.

With proper treatment, a full recovery is possible. Currently, the 5-year survival rate of patients with unilateral encapsulated dysgerminoma without metastases reaches 90%. In prognostic terms, metastases and germination beyond the ovary, large size and bilateral localization of dysgerminoma are unfavorable.

Teratoma. Mature teratoma refers to germ cell tumors. Depending on the differentiation of tissues, teratomas are divided into mature (dermoid cyst) and immature (teratoblastoma).

Mature teratomas are divided into solid (without cysts) and cystic (dermoid cyst). There are also monodermal teratomas - struma ovary and carcinoid ovary; their structure is identical to normal thyroid tissue and intestinal carcinoids.

Mature cystic teratoma is one of the most common tumors in childhood and adolescence; can occur even in newborns, which indirectly indicates its teratogenic origin. Mature teratoma occurs in reproductive age, in the postmenopausal period (as an accidental finding). It consists of well-differentiated derivatives of all three germ layers with a predominance of ectodermal elements (hence the term "dermoid cyst"). The tumor is a single-chamber cyst (a multi-chamber structure is rarely observed), is always benign and only occasionally shows signs of malignancy. The structure of dermoid cysts includes the so-called dermoid tubercle, in which mature tissues and rudimentary organs are revealed.

The capsule of the dermoid cyst is dense, fibrous, of various thicknesses, the surface is smooth, shiny. Teratoma on the cut resembles a bag containing a thick mass of fat and hair, in the form of balls or strands of various lengths, well-formed teeth are often found. The inner surface of the wall is lined with a cylindrical or cubic epithelium. Microscopic examination reveals tissues of ectodermal origin - skin, elements of neural tissue - glia, neurocytes, ganglia. Mesodermal derivatives are represented by bone, cartilage, smooth muscle, fibrous and adipose tissue. Derivatives of the endoderm are less common and usually include bronchial and gastrointestinal epithelium, tissue of the thyroid and salivary glands. The object of a particularly thorough histological examination should be the dermoid tubercle in order to exclude malignancy.

Symptoms dermoid cysts differs little from that of benign ovarian tumors. Dermoid cyst does not have hormonal activity, rarely causes complaints. The general condition of a woman, as a rule, does not suffer. Pain syndrome is noted in a small number of observations. Sometimes there are dysuric phenomena, a feeling of heaviness in the lower abdomen. In some cases, the pedicle of the dermoid cyst is twisted, and symptoms of an "acute abdomen" occur, requiring emergency surgical intervention.

The dermoid cyst is often combined with other tumors and tumor-like formations of the ovaries. Extremely rare in mature teratoma, a malignant process occurs, mainly squamous cell carcinoma.

Diagnosis established on the basis of the clinical course of the disease, two-handed gynecological examination, the use of ultrasound with color doppler, laparoscopy.

In a gynecological examination, the tumor is located mainly anterior to the uterus; it is rounded, with a smooth surface, has a long leg, mobile, painless, dense consistency. The diameter of a mature teratoma is from 5 to 15 cm.

Dermoid cyst with inclusion of bone tissue is the only tumor that can be identified on a plain x-ray of the abdominal cavity. Sonography helps to clarify the diagnosis of mature teratomas (pronounced acoustic polymorphism).

Mature teratomas have a hypoechoic structure with a solitary echogenic inclusion, with clear contours. Directly behind the echogenic inclusion is an acoustic shadow. Mature teratomas may have an atypical internal structure. Multiple small hyperechoic inclusions are visualized inside the tumor. In a number of cases, a weak enhancement effect, the "comet tail", is visualized behind small-lined inclusions. Perhaps a cystic-solid structure with a dense component with high echogenicity, round or oval in shape, with even contours. The polymorphism of the internal structure of the tumor often creates difficulties in the interpretation of echographic pictures (Fig. 16.18).

Rice. 16.18. mature teratoma. ultrasound

With CDI in mature teratomas, vascularization is almost always absent, blood flow can be visualized in the ovarian tissue adjacent to the tumor, IR is within 0.4.

As an additional method in the diagnosis of mature teratomas after the use of ultrasound, it is possible to use CT.

At laparoscopy, the dermoid cyst is of an uneven yellowish-whitish color; on palpation with a manipulator, the consistency is dense. A certain differential diagnostic value is the location of the cyst in the anterior fornix, in contrast to tumors of other types, usually located in the uterine-rectal space. The stalk of a dermoid cyst is usually long, thin, and there may be small hemorrhages on the capsule.

Treatment mature teratoma surgical. The volume and access of surgical intervention depend on the size of the mass formation, the age of the patient and concomitant genital pathology. In young women and girls, if possible, partial resection of the ovary within healthy tissue (cystectomy) should be limited. It is preferable to use a laparoscopic approach using an evacuation bag. In patients of perimenopausal age, supravaginal amputation of the uterus with appendages on both sides is indicated. It is permissible to remove the uterine appendages from the affected side if the uterus is not changed.

The prognosis is favorable.

Teratoblastoma (immature teratoma) refers to malignant neoplasms of the ovary. The tumor is extremely immature, low differentiation. Immature teratoma is much less common than mature. The tumor tends to grow rapidly and can reach a considerable size. Microscopic examination determines the combination of derivatives of all 3 germ layers. The cut surface is usually variegated, from pale gray to dark brown. On examination, bones, cartilage, hair are determined, the tumor contains fatty masses.

The tumor is usually located on the side of the uterus. It is one-sided, irregular in shape, unevenly soft, sometimes dense in consistency - depending on the predominant type of tissue and necrotic changes, large in size, with a bumpy surface, inactive, sensitive to palpation. When germinating, the capsule is implanted in the peritoneum, gives metastases to the retroperitoneal lymph nodes, lungs, liver, and brain. Metastases of an immature teratoma, like the main tumor, usually consist of various tissue elements with the most immature structures.

Patients complain of pain in the lower abdomen, general weakness, lethargy, increased fatigue, decreased ability to work. Menstrual function is often not disturbed. In the blood test, changes inherent in malignant tumors are noted. With rapid growth, the clinical picture due to intoxication, decay and metastasis of the tumor is similar to that in general somatic diseases. This often leads to inadequate treatment. By the time of recognition, the tumor is already running.

The use of echography with CFD helps to clarify the diagnosis. Sonographic pictures reflect a mixed, cystic-solid structure of an immature teratoma with uneven fuzzy contours. Like all malignant tumors, immature teratoma has a chaotic internal structure with pronounced neovascularization. With CDI, a pronounced mosaic pattern is visualized with turbulent blood flow and predominantly centrally located arteriovenous shunts. Decreased peripheral resistance index (IR<0,4).

Treatment surgical. Permissible supravaginal amputation of the uterus with appendages and removal of the omentum. Immature teratomas are insensitive to radiotherapy, but may sometimes respond to combination chemotherapy. The prognosis is unfavorable.

16.3. ovarian cancer

Early diagnosis and treatment of ovarian cancer remains one of the most difficult problems in oncology. Over the past 10 years, both in Russia and around the world, there has been a clear upward trend in the incidence of ovarian cancer. It consistently occupies the 2nd place in the structure of tumors of gynecological localization (after cervical cancer), and remains in the 1st place in terms of mortality.

Currently, the etiological factors of malignant ovarian tumors have not been reliably identified. There are three main hypotheses. According to the first, ovarian tumors occur in conditions of hyperactivity of the hypothalamic-pituitary system, resulting in chronic hyperestrogenism. Estrogens do not directly lead to tumor transformation of the cell, but create conditions under which the likelihood of cancer in estrogen-sensitive tissues increases. Another hypothesis is based on the concept of "incessant ovulation" (early menarche, late menopause, few pregnancies, shortened lactation). Constant ovulation leads to damage

reduction of the epithelium of the cortical layer of the ovary, which, in turn, increases the likelihood of aberrant DNA damage with simultaneous inactivation of tumor suppressor genes. According to the third, genetic hypothesis, high-risk individuals include family members with autosomal dominant breast and ovarian cancer.

According to world literature, hereditary forms of ovarian cancer are found only in 5-10% of patients. Advances in genetic engineering have made it possible to identify a number of oncogenes whose expression is associated with familial forms of ovarian cancer.

There is a relationship between the frequency of tumors of various morphological types and the age of patients. The peak incidence of ovarian cancer is observed between 60 and 70 years of age, but recently it has been fixed 10 years earlier.

Ovarian cancer can be primary, secondary and metastatic.

The specific frequency of primary cancer is no more than 5%. In primary cancer, the tumor is formed from the integumentary epithelium of the ovary, therefore, there is no mixture of benign and malignant elements in it. primary cancer called malignant tumors that primarily affect the ovary. According to the histological structure, primary ovarian cancer is a malignant epithelial tumor of a glandular or papillary structure (Fig. 16.19).

Secondary ovarian cancer(cystadenocarcinoma) is the most common and accounts for 80-85% of all forms of ovarian cancer; develops against the backdrop

Rice. 16.19. Serous papillary ovarian cancer (serous cystadenocarcinoma). Stained with hematoxylin and eosin, × 200. Photo by O.V. Zayratyan

benign or borderline tumors. Most often, secondary ovarian cancer occurs in serous papillary cystadenomas, less often in mucinous cystadenomas. Secondary ovarian lesions also include endometrioid cystadenocarcinoma.

Metastatic ovarian cancer(Krukenberg tumor) is a metastasis from the primary focus, which is most often located in the gastrointestinal tract, stomach, mammary gland, thyroid gland, uterus. Metastases from malignant tumors of the gastrointestinal tract spread by hematogenous, retrograde-lymphogenic and implantation routes. Metastases are usually bilateral. Ascites occurs in 60-70% of cases. The tumor grows very quickly. Macroscopically, the metastatic tumor is whitish, tuberous, often fibrous on cut. It can be dense or doughy consistency, which depends on the ratio of the stroma and parenchyma of the tumor, as well as secondary changes in the form of edema or necrosis. Microscopically, in metastatic cancer, ring-shaped round cells filled with mucus are determined.

Currently, the Unified International Classification has been adopted, which reflects both the stage of the process and the histological type of the tumor.

The stage of the tumor process is set on the basis of clinical examination data and during surgery.

Classification of ovarian cancer

Stage I - the tumor is limited to one ovary.

Stage II - the tumor affects one or both ovaries with spread to the pelvis.

Stage III - spread to one or both ovaries with metastases in the peritoneum beyond the pelvis and (or) metastases in the retroperitoneal lymph nodes.

Stage IV - spread to one or both ovaries with distant metastases.

clinical picture. The variety of morphological forms is one of the reasons for the heterogeneity of the clinical course of ovarian cancer. There are no pathognomonic signs. Localized forms of ovarian cancer, as a rule, remain asymptomatic; young patients sometimes experience pain up to a pronounced “acute abdomen” (22%) due to the possibility of torsion of the leg or perforation of the tumor capsule. In the rest of the patients, the symptoms appear due to the prevalence of the tumor process: intoxication, weight loss, general weakness, malaise, increased fatigue, decrease and perversion of appetite, fever, dysfunction of the gastrointestinal tract (nausea, vomiting, feeling of fullness in the epigastric region, heaviness lower abdomen, constipation alternating with diarrhea, dysuric phenomena). The abdomen is enlarged due to ascites. There may be an effusion in one or both pleural cavities. There are signs of cardiovascular and respiratory failure, edema in the lower extremities.

Diagnostics a malignant tumor can be difficult due to the lack of pathognomonic symptoms in the early stages of the disease. Malignant neoplasms do not have obvious clinical signs,

distinguish them from benign tumors. In this regard, patients at high risk for the development of ovarian tumors require special attention. These are women with impaired ovarian function, who are observed for a long time for tubo-ovarian inflammatory formations, recurrent hyperplastic processes of the endometrium in postmenopause, previously operated on for benign ovarian tumors, patients with impaired fertility.

With a two-handed gynecological examination, bilateral tumors of an oval or irregular shape, with a bumpy surface, a dense consistency, of various sizes, limitedly mobile and (or) immobile, are more often determined. Behind the uterus, dense painless formations protruding into the rectum - "thorns" are palpated.

In ovarian cancer, ascites is usually expressed. Rectovaginal examination is necessary to determine the invasion of the cancerous process into the pararectal and parametric tissue.

Modern diagnostics of malignant ovarian tumors includes transvaginal echography using high-resolution acoustic emitters and color flow, which allows visualizing the blood flow of the organ. Measurement of blood flow in systole and diastole makes it possible to judge the resistance of blood flow by calculating indicators of peripheral vascular resistance.

Echographically, a volumetric formation of considerable size is revealed, often bilateral, of irregular shape, with a thick, uneven capsule, with multiple papillary growths and septa (Fig. 16.20, 16.21). Partitions, as a rule, of unequal size, free fluid (ascites) is determined in the pelvis and in the abdominal cavity.

At color dopplerography in malignant tumors of the ovary, many vessels (zones of neovascularization) are determined both along the periphery and in the central structures of the tumor on the partitions and in papillary growths with low blood flow resistance (IR<0,4) (рис. 16.22,

16.23).

Rice. 16.20. Ovarian cancer.

ultrasound

Rice. 16.21. Ovarian cancer. Growth along the inner wall. 3D reconstruction

Rice. 16.22. Ovarian cancer. Ultrasound, CDC

Rice. 16.23. Ovarian cancer. Three-dimensional reconstruction of the newly formed vascular bed

CT and MRI.On computed tomograms, malignant neoplasms are visualized as volumetric formations, with uneven, bumpy contours, an inhomogeneous internal structure (areas of liquid and soft tissue density), a thickened capsule with internal partitions of unequal thickness. CT allows you to determine clear boundaries between the uterus, bladder and intestines and thereby identify the adhesive process in the pelvis.

Laparoscopy makes it possible to perform a biopsy with a morphological examination of the histiotype of the material and a cytological examination of the peritoneal fluid.

The content of tumor-associated antigens in the blood serum of patients correlates with the course of the disease. The markers CA-125, CA-19.9, CA-72.4 are of the greatest importance. CA-125, which are found in 78-100% of patients with ovarian cancer. The level of CA-125 exceeds the norm (35 IU / ml). In the initial forms of the tumor process, the specificity of CA-125 is low, so the tumor marker cannot be used as a screening test. CA-125 is of great value as a control for the effectiveness of treatment of common forms of the disease and for subsequent monitoring. In 80-85% of patients, the diagnosis can be established using the listed methods, although in some cases the final diagnosis is possible during laparotomy (Fig. 16.24).

Algorithm for examining patients with suspected ovarian cancer:

1) two-handed vaginal and rectovaginal examination;

2) Ultrasound of the pelvic organs with color doppler;

3) Ultrasound of the ovarian formation in 3D mode;

4) Ultrasound of the abdominal cavity, thyroid gland, mammary gland;

5) RKT;

6) MRI;

7) mammography;

8) fluoroscopy, gastroscopy, irrigoscopy, colonoscopy;

Rice. 16.24. Ovarian cancer. macropreparation

9) X-ray of the chest organs;

10) chromocystoscopy.

It is advisable to perform a chest x-ray to exclude metastases.

The stage of the malignant process, in addition to the above methods, can be clarified by chromocystoscopy (especially with large immobile ovarian tumors). Patients with a diagnosed or suspected ovarian tumor (regardless of stage) should be operated on.

Treatment. When choosing the tactics of treating patients with ovarian cancer, one should take into account the stage of the process, the morphological structure of the tumor, the degree of differentiation, the potential sensitivity of this histiotype of the tumor to chemotherapy and radiation treatment, aggravating factors, the patient's age, immune status, chronic diseases as a contraindication to a particular treatment method. .

Treatment of ovarian cancer is always complex. The leading, although not independent, method remains surgical: extirpation of the uterus and appendages and extirpation of the diseased omentum. In abdominal surgery, a lower median laparotomy is used. This ensures the removal of the tumor into the wound without disturbing its capsule, creates conditions for a thorough revision of the abdominal organs, and makes it possible, if necessary, to perform the operation in full.

In some patients (debilitated, elderly, with severe extragenital pathology), supravaginal amputation of the uterus with appendages and subtotal resection of the greater omentum can be limited. The greater omentum must be removed and subjected to morphological examination. Removal of the omentum prevents the subsequent development of ascites (Fig. 16.25).

In young patients with malignant neoplasms, removal of the uterine appendages on the affected side, resection of the other ovary, and subtotal resection of the greater omentum are acceptable. Similar

Rice. 16.25. Ovarian cancer. Metastasis to the omentum

operations can be performed only in patients with stage I malignant transformation of the ovary. In stage II ovarian cancer, a radical operation is performed, which involves extirpation of the uterus with appendages and resection of the omentum.

It is possible to accurately determine the stage of the disease only with a thorough revision of the abdominal cavity. Be sure to examine the peritoneal fluid, produce an audit of the para-aortic lymph nodes. Enlarged lymph nodes are punctured or biopsied for cytomorphological examination. If there is doubt about the patient's operability, it is advisable to perform surgical intervention at the 2nd stage, after chemotherapy, which increases the radicalness of surgical treatment in the future.

test questions

1. Give a classification of ovarian tumors.

2. Epithelial tumors of the ovaries. What are their diagnostics and management tactics?

28423 0

Liver masses are being diagnosed with increasing frequency, which is also explained by the proliferation of modern imaging techniques such as CT.

In most cases, liver lesions are not cancerous and sometimes do not even require treatment. However, the formations found in the liver cannot be taken lightly.

In US clinics, such diseases are treated by special multidisciplinary teams of doctors, including radiologists, hepatologists (specialists in liver diseases), oncologists and surgeons.

Benign tumors in the liver are usually divided into solid and cystic.

Solid formations in the liver

1. Liver hemangioma.

Hemangiomas are the most common benign liver tumors. They are more common in women and may be hormonal dependent. Symptoms of a hemangioma may include pain (usually with a tumor larger than 6 cm) associated with pressure on adjacent structures. Bleeding is rare. Diagnosis is by CT or MRI. For asymptomatic hemangioma, regardless of size, American physicians generally do not recommend any intervention. With a symptomatic tumor - surgical resection (removal).

2. Focal nodular hyperplasia (FNH).

Focal nodular (nodular) hyperplasia is the second most common benign tumor in the liver. It usually causes no symptoms, does not degenerate into cancer, and is not associated with a risk of rupture. Symptomatic FNH is usually large and causes compression of adjacent structures. Laboratory indicators are often normal, education is confirmed radiologically. Sometimes a biopsy is recommended. Surgical removal is indicated only when the formation bothers the patient or the diagnosis is in question.

3. Liver adenoma.

Liver adenomas are quite rare, and there is a very strong association with oral contraceptive use. Large adenomas can cause pain, discomfort, and a feeling of heaviness. Other symptoms include nausea, vomiting, fever. Large tumors can cause bleeding (40%), and in about 10% of cases become malignant. An MRI is used for diagnosis, sometimes a biopsy is required.

If the tumor was caused by taking oral contraceptives, then the treatment consists in the abolition of COCs with subsequent monitoring. American doctors recommend removing all adenomas where malignancy (malignant degeneration) cannot be ruled out.

4. Focal fatty changes.

Focal fat changes (FFC) occur more frequently in patients who have a history of diabetes mellitus, obesity, hepatitis C, or severe malnutrition. FFC can be asymptomatic, that is, do not disturb the patient. These formations are diagnosed with an MRI, and sometimes a biopsy is prescribed. Specific treatment is usually not required.

5. Nodular regenerative hyperplasia.

Nodular regenerative hyperplasia of the liver is very close to focal nodular hyperplasia. May cause symptoms associated with compression of adjacent structures. Occurs in autoimmune diseases such as rheumatoid arthritis. In some cases, it can degenerate into hepatocellular carcinoma (cancer).

Cystic formations in the liver

American experts recommend subdividing cystic masses in the liver into two broad categories: infectious and non-infectious.

Non-infectious cystic formations in the liver:

1. Choledoch cyst.

A choledochal cyst is a kind of expansion of the bile duct of the liver. May be congenital or formed during life. In the latter case, it is detected mostly by chance. If a choledochal cyst causes symptoms, then it may be pain, nausea, vomiting, fever, jaundice. Rarely, inflammation of the liver and cirrhosis can occur as a result of chronic obstruction (obstruction) of the bile ducts.

In a very rare hereditary condition, Caroli syndrome, saccular dilatation of the ducts can also be seen. Diagnosis requires imaging and biopsy of the bile duct to rule out cancer. Surgical treatment.

2. Simple liver cyst.

A simple liver cyst is a hollow formation, mostly solitary, filled with fluid. A simple cyst may be present from birth and remain undiagnosed until the age of 30 or 40. Sometimes a cyst causes symptoms: pain, discomfort, a feeling of fullness. Diagnosed radiologically. Symptomatic cysts can be treated by marsupialization (incision and emptying of the contents of the cyst), sometimes a partial liver resection is required.

3. Polycystic liver disease (PCLD).

Polycystic liver disease is an inherited disease that may be associated with cystic masses in the kidneys. Most patients do not have any symptoms, laboratory tests are normal. Hepatic cysts are numerous and tend to grow slowly. The symptoms are similar to a simple liver cyst. Ultrasound and CT scanning reliably identify these formations.

The United States has long developed genetic tests that detect PCLD and assist in genetic counseling for couples. Treatment for polycystic liver disease is the same as for simple cysts. If necessary, patients are placed on a waiting list for liver or kidney transplants if these organs are damaged too badly.

Infectious cystic formations in the liver:

1. Liver abscess.

Liver abscess is bacterial in origin. There are many situations in which a bacterial infection can enter the liver and cause an abscess. Pathological processes inside the bile ducts, which are accompanied by their obstruction, are responsible for most cases of abscess formation in the liver.

Other possible causes: abdominal infections, liver injury, some liver cancer therapies (TACE, RFA). In addition, infections from distant sites (dental infections or endocarditis) can travel to the liver and cause an abscess. According to American doctors, in 55% of cases the exact cause of the abscess cannot be established. Symptoms of a liver abscess include fever, chills, nausea, vomiting, abdominal pain, and loss of appetite. A serious complication is the rupture of the abscess. Treatment: antibiotic therapy, surgery.

Amoebic abscesses are common in people who have a weak immune system, are malnourished, or have cancer. Before the formation of a hepatic abscess, intestinal symptoms are observed in less than 1/3 of patients. Abscess symptoms include fever, sharp pain, and slight jaundice (8%). In 95% the antibody test is positive. Diagnosis is made using CT or ultrasound. Treatment: infection control, sometimes aspiration of abscess, surgical treatment.

With an echinococcal cyst of the liver, the patient may be disturbed by pain and a feeling of heaviness. Pain is usually noted when the cyst becomes infected or ruptures. In some patients, an acute allergic reaction occurs upon rupture.

Echinococcal cysts are diagnosed radiologically. In the United States, blood tests for antibodies are widely used to confirm invasion. Treatment includes chemotherapy (mebendazole and albendazole) and surgery (drainage or radical removal).

Konstantin Mokanov

A cyst is seen as a benign tumor in the form of a sac that contains fluid. The dimensions of this formation can vary from a few mm to 15 cm. It can also have a different localization, both inside and outside the organ. The tumor affects the ovary, kidneys, liver, urethra, pancreas, thyroid and mammary glands, can be detected on the coccyx and some other organs.

Signs of a cyst in a woman are most often absent. This pathology manifests itself clinically only with a significant increase in the cyst and compression of nearby organs.

Cystic formation can be diagnosed in a woman of any age. Often it spontaneously disappears, and then reappears. You can read about why cysts form at.

There are several types of cysts in women. The causes of this or that cystic formation are different. There are several common factors that contribute to their occurrence.

Among the reasons for the formation of cysts are:

• Disturbed menstrual cycle. A woman may complain about the prolonged absence of menstruation or, conversely, their long duration. Any violation of menstruation is due to hormonal failure, which can lead to the formation of a cystic cavity.
• Changed hormonal background. This can provoke the occurrence of a cyst, as well as adversely affect the process of its treatment.
• Operational interventions. Any surgical manipulation can provoke the formation of cysts in the future. At risk are women who have undergone a caesarean section, abortion or any other surgical intervention.
• Frequent stress. In people whose lives are full of experiences, metabolic processes are often disrupted, and pathology of the endocrine glands also occurs. These changes can provoke the formation of cystic neoplasms.
• Long-term use of hormones. These medicines must be taken under the strict supervision of a physician. Replacement of the drug should also be done in a timely manner, which will exclude the development of adverse effects in the future.
• Infectious processes in the body. Absolutely any infection can provoke the formation of a cyst, so you should treat all emerging diseases in a timely manner. Cysts in the ovary also form with frequent changes of sexual partners.

To make a correct diagnosis and subsequent productive treatment, it is necessary to understand in detail the type of tumor, as well as the features of its treatment.

There are many types of cystic formations. Cysts are classified most often depending on the cause of their appearance and the nature of their contents.

There are cysts:

1. . This cyst can be luteal (the work of the corpus luteum is disrupted) and follicular (the cause of which is an unruptured Graafian vesicle). In menopausal women, this pathology cannot be diagnosed.
2. endometrial character. This cyst appears as a result of excessive growth of endometrioid cells. The size of the formation can be huge, reaching 20 cm. Women complain of constant pain and irregular menstruation. Often, a is torn, which forces a woman to urgently go to a hospital.
3. . Usually this is a congenital formation that contains bones, hair, cartilage. Its formation occurs in embryogenesis. Characterized by the absence of clear symptoms. This type of cyst requires prompt removal.
4. Formation. Also, this formation is called a serous cyst, it is multi-chambered and has a great tendency to spontaneous ruptures.

Serous cysts

This group of cysts is characterized by the formation inside the ovary (papillary tumor) or directly on the fallopian tube (paraturbar tumor).

Paraturbar tumors are diagnosed quite often. Their size is usually no more than 2 cm, they are filled with serous fluid and may contain several chambers. A distinctive feature of these cystic formations is the inability to transform into an oncological process.

Papillary cysts are located near the uterus. They are single-chamber, filled with transparent contents. In the process of growth, they can cause discomfort in a woman. Education data will be deleted without fail.

Fibrous tumors

Another type of cyst is fibrous. It is represented by dense connective tissue and is much more difficult to treat than other cystic formations. In the case of hormonal disruptions, the likelihood of rapid tumor growth is high. This type of cyst includes dermoid, cystic adenoma, as well as pseudomucinous cyst, which can transform into a cancerous tumor.

Fibrous tumors are often diagnosed on the chest. In the first stages, the tumor does not manifest itself in any way, but subsequently a woman may complain of discomfort in the mammary gland. The cyclical nature of pain is characteristic, in which its intensification is observed before and after menstruation.

Among the reasons for the formation of fibrous growths is an increase in the duct of the mammary gland as a result of the secret accumulated in it, followed by the formation of a capsule. The size of the cyst ranges from a few mm to 5 cm.

Atypical formations

This formation is similar to a fibrous cyst. Its difference is the proliferation of cells inside an atypical formation.

Perhaps the development of an inflammatory process in the cavity of the cyst. As a result, a woman's temperature rises, breast tenderness occurs, and an increase in regional lymph nodes is noted.

Cyst symptoms in a woman

The symptomatology of cystic formations of various types has a certain similarity. All of them do not manifest themselves in the initial stages, and only after a significant increase in their size, certain symptoms appear, which include:

• Lack of pregnancy for a long time;
• Disturbed menstrual cycle. This is due to the intensive production of hormones by cysts;
• Pain during sexual intercourse;
• A large cystic mass may be palpable through the anterior abdominal wall;
• Complaints of soreness of the lower back with irradiation to the leg;
• Impaired urination, characterized by pain and frequent urination. Often, the presence of a paraurethral cyst leads to such manifestations.

Depending on the location of the cyst, with its active growth, the formation can be felt.

Dangers and Consequences

If the pathology is not treated in a timely manner, the following dangerous consequences may occur:

• Torsion of the cyst leg. At the same time, the woman feels pain in the lower abdomen, which requires immediate hospitalization.
• Cyst apoplexy. More often, this condition accompanies tumors of the corpus luteum and is characterized by the formation of hemorrhage. This situation also requires emergency care.
• Soldering process. In addition to severe pain in the lower abdomen, infertility is diagnosed. Such complications often occur with endometrioid cysts.
• Process degradation. The provoking factors in this case are hormonal disorders, improper treatment, poor environmental conditions.
• development of infertility. This formidable complication can be diagnosed even after removal of the cystic formation.

Often the question arises whether a tumor formation is dangerous during pregnancy. The cyst should be identified and removed during pregnancy planning. If the diagnosis is made already while waiting for the baby, the doctor in each case gives his recommendations regarding the treatment or removal of the tumor. Hormonal changes that occur during pregnancy can cause a cyst to grow rapidly and be more likely to rupture.

Regular visits to the doctor will help to avoid complications.

Treatment of cysts in women

Therapeutic tactics when a cystic formation is detected is determined by the location, size, and nature of the cyst.

Be sure to contact a qualified specialist to select the optimal method of treatment, since in each situation the treatment is individual.

If the size of the cyst does not exceed 5 cm, they try to treat it with medication. In this case, you should be regularly observed by a specialist and undergo the necessary examinations to monitor the process of therapy. In addition to the main treatment, physiotherapy is usually prescribed. Most often, balneotherapy, electrophoresis and some other methods are used.

With the ineffectiveness of conservative methods, laparoscopic removal of the cyst is performed. This method allows the patient to recover in a short time after the operation. Often there is a need to remove part of the organ along with the tumor.

With timely contacting a medical institution and following all medical recommendations, the treatment of the cyst will be successful and will end in complete recovery.